What's the Buzz on Health Care?

Boom to Bust in retail medical clinics.

It sounded like a good idea at first: put a medical clinic in a major store, such as Target or Wal-Mart – or, even better, in pharmacies, such as CVS - then staff it with a nurse, have an all "cash" price list, and make money off of volume while "feeding" the retail store itself.

The concept of medical clinics in retail outlets certainly seemed to make sense. However, medical business leaders across the country are now acknowledging that this strategy has not been successful.

The Wall Street Journal recently reported that 69 clinics in 15 states based in Wal-Marts and Medicine Shoppes have been shut down. Minute Clinic, owned by CVS Corporation, has announced it would shutter 89 clinics either permanently or until the next cough and cold season.

One of the main reasons for these failures is that family physicians and other primary care physicians are now commonly offering same-day care as well as cash prices. This robs the retail clinics of its core target audience.

A second obstacle has been the recession, which has caused many Americans to reign in spending of any type, especially cash health expenditures.

Another theory was a miscalculation of the number of patients that would leave the safety net of their family physician or local emergency room for the uncharted waters of a retail clinic staffed by non-physicians in a new location. Some studies now suggest that medical care is not driven to the same price and convenience points with which food and groceries have been identified.

Additionally, the Federal Trade Commission and some local governments have placed significant restrictions on retail health clinics in some states, such as Illinois and Massachusetts. These political concerns revolve around fear that the new clinics would draw off younger and healthier patients who cost less to treat, leaving the more traditional providers with an older and sicker – and thus more expensive – population.

In addition to closing clinics, Minute Clinic has laid off staff and reduced overhead wherever possible. They report that a typical clinic generates approximately $450,000.00 in sales, but that is at least 20 to 30% below initial projections. These original projections were based on a steady patient flow on a 12-hour a day /seven day per week schedule.

Recently the American College of Physicians and the American Medical Association have adopted guidelines for retail clinics. These include improving physician supervision and increased lines of communication between the clinics and the primary physicians. Compliance with these guidelines has been spotty at best.

Yul Egnes, MD, a board member of the American College of Physicians, perhaps said it best by calling the projected boom and subsequent bust in retail clinics "just a symptom of a bigger problem and a sign of a dysfunctional health care system."

WellPoint Health Plan may restrict coverage on vitamin D testing in seniors

One concern being voiced over the newer health care proposals being proposed is that the government may restrict certain diagnostic tests as well as treatments in the name of being cost effective. In a preview of this concern, a major Medicare carrier is planning significant coverage restrictions on vitamin D testing.

This is causing a great deal of protest among endocrinologists.

The coverage decision would deny all coverage for vitamin D assay as not being medically necessary for any diagnosis including chronic kidney disease and end-stage renal disease. In the draft decision WellPoint states, “Treatment of vitamin D deficiency is relatively straightforward, negating the need for measuring vitamin D levels.

Dr. Steven Petak, past President of the American Association of Clinical Endocrinologists said, “In addition to the benefits of adequate vitamin D on bone health, it has been implicated in an increased risk of cardiovascular disease. The risk of falls that result in fractures is increased with vitamin D deficiency because of changes in muscle tone and balance.” He continued, “It is a monetary thing. Medicare has probably seen the tests for vitamin D levels are being done in increasing numbers, and they are trying to put a lid on it. Unfortunately the real victims here are the patients.”

M.D. CONSULT CONTRIBUTED TO THIS STORY.

Cost issues are cited as barriers providing herpes zoster vaccine in primary care offices.

According to an article published in Global Medical News, a 2007 National Immunization Survey found that just 1.9% of eligible adults received the HZV, also known as the "shingles vaccine." In 2008, the rate does not appear to have improved much.

A CDC funded survey of members of the American Academy of Family Physicians and the American College Physicians revealed that only 51% said that they stock the HZV in their offices, while 33% refer their patients to a pharmacy for vaccine purchase or administration. Although 41% of respondents said they "strongly recommend" the shingles vaccine to eligible patients, that compares to 94% for the pneumococcal vaccine and 96% for the influenza vaccine.

The major barrier appears to be cost concerns with 52% of respondents listing reimbursement problems as a "major barrier."

Interestingly, only 45% knew that the cost of the HZV was reimbursed under Medicare, Part D compared to 39% said they did not know if the vaccine was covered under Medicare.

The CDC’s National Center for Immunization noted that, at an average wholesale price of nearly $200.00, the HZV is the most expensive vaccine recommended for older adults (60 years and older). It is the first vaccine reimbursed through Medicare, Part D, which is administered by contracts with pharmacies, not physicians.

For physicians, shingles vaccines usually entail having the patients pay up front in full, and perhaps filing the paperwork for reimbursement later. Of concern is that some physicians have had the patient pick up the vaccine at the pharmacy and bring it to the office for administration. This practice known as "brown bagging" is strongly discouraged because a vaccine must be kept frozen and can lose potency if thawed.

The CDC plans on a program to educate both patients and physicians on the vaccine being reimbursed through Medicare, Part D, including both the cost of the vaccine and administration.